McMaster University, Hamilton, Ontario, Canada.
University of Cape Town, Cape Town, South Africa.
JAMA. 2017 Apr 25;317(16):1642-1651. doi: 10.1001/jama.2017.4360.
Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS).
To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality).
DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013.
Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement.
A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality.
Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom.
Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.
重要性：关于围手术期高敏肌钙蛋白 T（hsTnT）测量与非心脏手术后 30 天死亡率和心肌损伤（MINS）之间的关系，知之甚少。
目的：确定围手术期 hsTnT 测量与 30 天死亡率之间的关联，并确定 MINS 的潜在诊断标准（即与 30 天死亡率相关的缺血引起的心肌损伤）。
设计、地点和参与者：这是一项前瞻性队列研究，纳入了年龄在 45 岁及以上、接受住院非心脏手术且术后 hsTnT 测量的患者。研究于 2008 年 10 月在 13 个国家的 23 个中心开始招募参与者，随访于 2013 年 12 月结束。
暴露：患者在手术后 6 至 12 小时和接下来的 3 天每天进行 hsTnT 测量；40.4%的患者有术前 hsTnT 测量。
主要结果和测量：采用改良的 Mazumdar 方法（迭代过程）来确定是否存在与死亡风险相关的 hsTnT 阈值，并且该阈值的调整后危险比（HR）为 3.0 或更高，30 天死亡率为 3%或更高。为了确定 MINS 的潜在诊断标准，回归分析确定术后 hsTnT 升高是否需要缺血特征（例如，缺血症状或心电图发现）与 30 天死亡率相关。
结果：在 21842 名参与者中，平均年龄为 63.1（标准差，10.7）岁，49.1%为女性。术后 30 天内死亡的患者有 266 例（1.2%；95%CI，1.1%-1.4%）。多变量分析表明，与参考组（峰值 hsTnT<5ng/L）相比，术后 hsTnT 水平为 20 至<65ng/L、65 至<1000ng/L 和 1000ng/L 或更高的患者，30 天死亡率分别为 3.0%（123/4049；95%CI，2.6%-3.6%）、9.1%（102/1118；95%CI，7.6%-11.0%）和 29.6%（16/54；95%CI，19.1%-42.8%），相应的调整后 HR 分别为 23.63（95%CI，10.32-54.09）、70.34（95%CI，30.60-161.71）和 227.01（95%CI，87.35-589.92）。hsTnT 绝对值升高 5ng/L 或更高与 30 天死亡率增加相关（调整后 HR，4.69；95%CI，3.52-6.25）。没有缺血特征的术后 hsTnT 升高（即 20 至<65ng/L，绝对变化≥5ng/L 或 hsTnT≥65ng/L）与 30 天死亡率相关（调整后 HR，3.20；95%CI，2.37-4.32）。在 3904 例（17.9%；95%CI，17.4%-18.4%）有 MINS 的患者中，3633 例（93.1%；95%CI，92.2%-93.8%）没有发生缺血症状。
结论：在接受非心脏手术的患者中，术后前 3 天的 hsTnT 峰值与 30 天死亡率显著相关。没有缺血特征的升高的术后 hsTnT 也与 30 天死亡率相关。
